Midfoot Fractures and Dislocations

Brian Weatherford, MD Illinois Bone and Joint Institute

Outline 1. Anatomy of the Tarsometatarsal joint complex 2. Physical exam and imaging findings 3. Treatment options

– Nonoperative – ORIF – Arthrodesis

4. Review current literature 5. Case examples 6. Associated injuries

– Cuboid 7. Summary

Objectives

Understand 1. Functional anatomy of the midfoot 2. Stress imaging 3. Goals of treatment 4. Indications for operative treatment 5. Primary Arthrodesis versus ORIF

Recommendations to Improve Retention of this Material

1. Write down the objectives

2. Search for the answers to the objectives in the powerpoint talk (hint: look for orange text)

3. Test yourself at the end by reviewing the objectives

4. Watch the show on “presenter view” and look at the notes at

the bottom of the slides. References are listed throughout.

Acknowledgement to Dr. Matt Graves for this concept

Incidence • Rare injuries • 0.2% of all fractures • Up to 20% initially

missed • High index of suspicion

is necessary – Lisfranc injury until

proven otherwise

Anatomy • Trapezoidal

configuration • *Recessed 2nd

Tarsometatarsal (TMT) joint • “keystone” of the

transverse arch* • Individual joints are

“flat on flat” Siddiqui et al. Evaluation of the tarsometatarsal joint using conventional radiography, CT, and MR imaging. Radiographics. 2014

Anatomy • Transverse

Intermetatarsal ligaments secure M2-M5

• *No intermetatarsal ligament between M1-M2*

• *Interosseous C1-M2 ligament = Lisfranc ligament*

• Plantar ligaments stronger than dorsal ligaments Panchbhavi et al. Three-dimensional, digital, and gross anatomy of the

Lisfranc ligament. Foot Ankle Int. 2013

Anatomy

• Dynamic Stabilizers – Peroneus Longus – Tibialis posterior – Tibialis Anterior

• May block reduction

• Dorsalis pedis artery – Forms plantar arch – May be avulsed causing

hematoma or compartment syndrome

Schildhauer et al. Ligamentous Structure of the midfoot. In: Bucholz et al., editors. Rockwood and Green’s fractures in adults. 8th ed

Functional Anatomy Column Theory • Medial column (Yellow)

– First TMT and NC joints – Limited mobility at first

TMT – Mobile segment is the

talonavicular joint

Yellow shading = medial column, red shading = intermediate column, green shading = lateral column

Functional Anatomy Column Theory • Intermediate column

(Red) – 2nd , 3rd TMT joints

and NC joints – Rigid (no motion)

Yellow shading = medial column, red shading = intermediate column, green shading = lateral column

Functional Anatomy Column Theory • Lateral Column (Green)

– 4th and 5th TMT joints

– Mobile – Essential

• Shock absorber

Yellow shading = medial column, red shading = intermediate column, green shading = lateral column

Functional Anatomy Column Theory • Medial and

Intermediate Columns are rigid • Lever for propulsion

• Lateral column is mobile • Shock absorber • Accommodate to uneven

surfaces

Yellow shading = medial column, red shading = intermediate column, green shading = lateral column

Mechanism of Injury Direct vs Indirect • Indirect with axial

force to plantarflexed foot – Weaker dorsal ligaments

fail under tension • Direct = crushing

mechanism – Concern for soft tissue

compromise or compartment syndrome

Initial Evaluation

• Careful History – Ability to weight bear? – Push off?

• Physical Exam – *Plantar arch

ecchymosis* – Gap sign – Provocative maneuvers

• Pronation abduction stress • Dorsal/plantar translation

Gap sign

Imaging

• AP • Up to 3 mm normal

between 1st and 2nd metatarsal bases

• Lateral base 1st MT in-line with lateral aspect of medial cuneiform

• Medial base 2nd MT in-line with medial aspect of middle cuneiform

Imaging

• 30 degree oblique – Medial base 3rd MT

in-line with medial aspect of lateral cuneiform

– Medial base 4th MT in-line with medial aspect of cuboid

Imaging Lateral: A metatarsal should never be more dorsal

than its respective tarsal bone

Fleck Sign

• Indicative of avulsion of the Lisfranc ligament

• High suspicion for ligamentous instability

Advanced Imaging • CT scan

– Articular comminution – Non displaced fracture

lines – Helpful for preop

planning – Not dynamic!

• Does not demonstrate how foot tolerates physiologic load

Advanced Imaging • MRI

– Ligamentous injury – *Plantar Oblique

Ligament* • Disruption is predictive

of instability on EUA • Raikin et al, JBJS 2009

– Not dynamic! • Does not

demonstrate how foot tolerates physiologic load

Stress Imaging

• Weight bearing X-ray • Contralateral view for

comparison • Dynamic evaluation

• How foot responds to physiologic load

• First line of imaging • Before more costly

advanced studies

Stress Imaging

Classification • Multiple classifications • Does not direct

treatment • Myerson classification

most commonly used • Based on Quenu and

Kuss

Watson TS, Shurnas PS, Denker J. Treatment of Lisfranc joint injury: current concepts. J Am Acad Orthop Surg. 2010 Dec;18(12):718-28.

Treatment Principles

• MUST – Restore alignment – Protect talonavicular motion – Protect 4,5 TMT motion

• Motion of other joints not essential for function

Treatment Principles • Hindfoot: Protect ankle, subtalar, and

talonavicular joints

• Midfoot: restore length and alignment of medial and lateral “columns”

• Forefoot: Even weight distribution across metatarsal heads

• GOAL IS A STABLE, PLANTIGRADE FOOT

Management • Nonoperative

– Rule out instability – Negative stress imaging – Examine under anesthesia

if necessary – Short leg cast or boot,

NWB x 6-8 weeks

Management

• Operative – Multiple base fractures – Articular displacement – Static instability – Dynamic instability

(How much?)

Initial Management • Closed reduction

– Minimize risk of skin compromise

• Provisional Fixation – Indications:

• Inability to maintain reduction • High energy patterns • Multiply injured patient

– Ex-Fix – Percutaneous screws or

wires Kadow TR, Siska PA, Evans AR, Sands SS, Tarkin IS. Staged treatment of high energy midfoot

fracture dislocations. Foot Ankle Int. 2014 Dec;35(12):1287-91

Initial Management

Courtesy of John Anderson, MD

Compartment syndrome

• Highest incidence with forefoot crush

• Consider compartment pressure measurement

• Treatment is controversial

• Calcaneal compartment communicates with deep posterior compartment of leg

Thakur NA, McDonnell M, Got CJ, Arcand N, Spratt KF, DiGiovanni CW. Injury patterns causing isolated foot compartment syndrome. J Bone Joint Surg Am. 2012 Jun 6;94(11):1030-5

Definitive Management is Controversial

ORIF • Joint preserving surgery

• Hard to make the multiple

fractures and a fusion heal

• Better than previous treatments (K-wires/cast)

• Established treatment with reasonable outcomes

Primary Arthrodesis • Medial and intermediate columns

are rigid • Fusion restores FUNCTIONAL

anatomy

• Lateral column is mobile • Preserve if at all possible

• One operation

• Fusion after failed ORIF is

technically difficult • With worse outcomes

• High rates of arthritis despite ORIF

The Problem

These are both midfoot injuries

These are both ankle injuries

They are not the same in any way …Like comparing Apples to Elephants

The Problem

• Heterogeneity • High energy midfoot crush injury will have a

different outcome than low energy midfoot sprain regardless of surgical treatment

• Both injuries are grouped under the umbrella of “Lisfranc injuries”

OUTCOMES

• Kuo et al, JBJS 2000 • 48 patients – 55 month followup

• AOFAS score 77 • 12 post-traumatic OA (6 fusion)

• 6 of 15 with ligamentous injury* • Better results with anatomic reduction

• 58 patients (29 ligamentous vs 29 osseous) – All treated with ORIF

• No significant difference in AOFAS Midfoot score, FFI, SF 36

• Authors relate their improved results to longer immobilization (3 months vs 2 months) and the use of an arch support… – “The formation of solid and reliable SCAR after

ligamentous Lisfranc likely takes longer…”

• 61 patients at mean of 10.9 years – 50 ORIF (82%) and 11 PA (18%)

• 72% radiographic arthritis • 54% clinically symptomatic arthritis

– 33 of 61 patients • Should this be 33 of 50 (66%)??

• Worse functional outcomes with arthritis

Primary Arthrodesis(PA) vs ORIF

PA vs ORIF Ly and Coetzee, JBJS 2006

• Level I, Prospective randomized • 41 patients (21 ORIF, 20 PA), 2 year followup • All results in favor of PA

– AOFAS Midfoot, Patient function • ORIF group

– 15 of 21 ORIF with radiographic arthritis – 5 of 21 converted to arthrodesis

• 2 more scheduled for fusion at time of publication

Operative Technique • Dorsomedial incision

between 1st and 2nd TMT joints • *Superficial peroneal

nerve • Lateral to EHL • NV bundle lateral to

EHB • Visualize:

• 1st TMT joint, 2nd TMT joint, IC joint

Exposure: Dorsomedial Superficial peroneal nerve branches

1st TMT joint 2nd TMT joint

Exposure: Dorsolateral

• Dorsolateral incision in line with 4th ray • Check under fluoro • AVOID NARROW

SKIN BRIDGE • Visualize:

• Lateral aspect of 2nd TMT, 3rd/4th TMT, Lateral IC joint

Sequence of Reduction • Start medial/proximal • Work lateral/distal

Intercuneiform Joint

First TMT joint

2nd metatarsal base in

“keystone”

Third TMT joint, etc… DISCLAIMER: This is just one approach to the sequence of reduction. This is not the only way it can be done.

Fixation

Fixation

• Rigid Fixation for rigid joints • 1st/2nd/3rd TMT joints • 4.0/3.5/2.7 solid

screws • Flexible fixation for

mobile joints • 4th/5th TMT joints • K wires

Fixation: ORIF

• For open reduction and internal fixation screws are placed in positional mode

• Maintain alignment • No compression

Fixation: Arthrodesis

• For arthrodesis screws are placed in lag mode

• Generate compression to assist with fusion

Closure

Case Examples

Case Example # 1

Fixation for Case #1

Follow up

Follow up

Case example # 2 Bridge plating to maintain length

ORIF

Bridge plate to maintain medial column

Schildhauer TA, Nork SE, Sangeorzan BJ. Temporary bridge plating of the medial column in severe midfoot injuries. J Orthop Trauma. 2003

Follow up

Case Example # 3: Plate fixation for comminution

Post reduction

Unable to maintain closed reduction

Note the flexible fixation of the lateral column

Follow Up

Associated Injuries: Cuboid Fracture

• Abduction force • Compressive failure

• “Nutcracker” fracture • Indications for ORIF

• Articular displacement • 2mm?

• Lateral column shortening • Complex fractures/significant shortening

• Consider bridge plate or external fixator

Cuboid Fracture

Simple patterns can be treated with direct reduction and fixation

Cuboid Fractures: Bridge Plating

Cuboid Fractures: Bridge plate

Cuboid Fractures: Ex-Fix Courtesy of John Anderson, MD

Indications for Fusion of Lisfranc Injuries

Recommend Reading: Coetzee JC. Making sense of lisfranc injuries. Foot Ankle Clin. 2008 Dec;13(4):695-704,

• Ligamentous injuries with multiplanar instability

• Multiple joint dislocations or fracture dislocations

• Intra-articular comminution

Objectives (Again)

Understand 1. Functional anatomy of the midfoot 2. Stress imaging 3. Goals of treatment 4. Indications for operative treatment 5. Primary Arthrodesis versus ORIF

Summary • Complex injuries with historically poor

outcomes • Do not miss subtle injuries • Arthrodesis vs. ORIF – still controversial • Arthrodesis is not a panacea

• Long term outcomes? • Adjacent joint arthritis?

• Goal Stable, plantigrade foot

References • Siddiqui et al. Evaluation of the tarsometatarsal joint using conventional

radiography, CT, and MR imaging. Radiographics. 2014 • Panchbhavi et al. Three-dimensional, digital, and gross anatomy of the

Lisfranc ligament. Foot Ankle Int. 2013 • Schildhauer et al. Ligamentous Structure of the midfoot. In: Bucholz et al.,

editors. Rockwood and Green’s fractures in adults. 8th ed • Reid JJ, Early JS. Osseous anatomy of the midfoot. In: Bucholz et al., editors.

Rockwood and Green’s fractures in adults. 7th ed • Raikin SM, Elias I, Dheer S, Besser MP, Morrison WB, Zoga AC. Prediction

of midfoot instability in the subtle Lisfranc injury. Comparison of magnetic resonance imaging with intraoperative findings. J Bone Joint Surg Am. 2009 Apr;91(4):892-9

• Coss HS, Manos RE, Buoncristiani A, Mills WJ. Abduction stress and AP weightbearing radiography of purely ligamentous injury in the tarsometatarsal joint. Foot Ankle Int. 1998 Aug;19(8):537-41

• Kadow TR, Siska PA, Evans AR, Sands SS, Tarkin IS. Staged treatment of high energy midfoot fracture dislocations. Foot Ankle Int. 2014 Dec;35(12):1287-91

• Thakur NA, McDonnell M, Got CJ, Arcand N, Spratt KF, DiGiovanni CW. Injury patterns causing isolated foot compartment syndrome. J Bone Joint Surg Am. 2012 Jun 6;94(11):1030-5

References • Kuo RS, Tejwani NC, Digiovanni CW, Holt SK, Benirschke SK, Hansen ST

Jr, Sangeorzan BJ. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am. 2000 Nov;82-A(11):1609-18

• Abbasian MR, Paradies F, Weber M, Krause F. Temporary Internal Fixation for Ligamentous and Osseous Lisfranc Injuries: Outcome and Technical Tip. Foot Ankle Int. 2015 Aug;36(8):976-83

• Dubois-Ferrière V, Lübbeke A, Chowdhary A, Stern R, Dominguez D, Assal M. Clinical Outcomes and Development of Symptomatic Osteoarthritis 2 to 24 Years After Surgical Treatment of Tarsometatarsal Joint Complex Injuries. J Bone Joint Surg Am. 2016 May 4;98(9):713-20.

• Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg Am. 2006 Mar;88(3):514-20

• Schildhauer TA, Nork SE, Sangeorzan BJ. Temporary bridge plating of the medial column in severe midfoot injuries. J Orthop Trauma. 2003

• Coetzee JC. Making sense of lisfranc injuries. Foot Ankle Clin. 2008 Dec;13(4):695-704, ix. doi: 10.1016/j.fcl.2008.07.001. Review.